Understanding how Rivet calculates "actuals" and how to effectively compare these figures with your current system's reporting can ensure accuracy and transparency in your financial analysis. We'll cover how Rivet processes claim and remit files, the importance of matching comparison metrics and troubleshooting common discrepancies.
1. Understanding Rivet's Calculation of Actuals
Rivet's Revenue Diagnostics relies on raw 837 (claim) and 835 (remittance/EOB) files. These files are typically ingested on an hourly or nightly basis, forming the foundation of the "Actuals" calculation.
2. Compare Your System's Actuals with Rivet's
First, make sure that you are looking at the correct tab in Rivet. Determine whether your existing system is displaying the metric you’re evaluating based on the date of service or the date of payment, and use the same tab in Rivet.
For example:
The “Date of service” tab might make more sense if you’re looking at billed claims and gross charges
The “Billed date” tab might make sense for the same use cases as above if your system uses the transaction date on claims rather than their dates of service.
The “Date of payment” tab might make more sense if you’re looking at net revenue or denial rates
If you see a discrepancy between the “actual” value Rivet is showing and what your existing system is showing, proceed to the following sections to help troubleshoot. To investigate which scenario may affect you, export your selection via the top right “Export” button.
3. Troubleshooting Common Discrepancies
Handling of Paper Claims and Remits: Since Rivet relies on electronic claims and remits, we do not currently display paper claims or remits in the product. Depending on the amount of your practice’s claims/remits that are paper, your actual metrics in Rivet may be lower than the true amounts due to the paper claims/remits that are not represented in Rivet.
Date of Payment Tab Functionality: Rivet’s date of payment tab includes claims with any date of service that were adjudicated within the timeframe selected. Some systems/excel models show you a “date of payment” view that only takes into account certain dates of service. We believe Rivet’s approach is more accurate because some claims can take over a year to be paid and those should be accounted for too, but this may result in a difference when comparing with an existing report outside of Rivet.
Discrepancies in Claim Counts: Rivet's methodology for counting claims excludes $0 claims and counts multiple rebills of the same claim as one. This can result in a lower claim count in Rivet compared to reports that count each billing instance separately.
Patient Responsibility Reporting: Rivet does not currently ingest real patient payments. Therefore, the “patient receivables” rows in the actual columns represent what is owed by patients according to remits we’ve received from payers. This is different from what was paid by patients. If your report from another source includes patient payments in its actual net revenue, Rivet’s actual net revenue will appear higher because it displays how much you are owed by patients, not how much has been paid. Removing patient payments from your report and comparing that to Rivet’s actual payer revenue is more of an apples-to-apples comparison.
Addressing Claim/Remit Data Errors: Occasionally, discrepancies can arise from errors in the claims or remittances received by Rivet. While our software is designed to identify and correct many common issues, some errors may still affect reported data. Users can investigate specific claims or patient names within Rivet for further clarification.
If you have any additional questions about Revenue Diagnostics or see any discrepancies feel free to chat in or send an email to support@rivethealth.com.
Suggested next article -Navigating Rivet’s Revenue Diagnostics